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	<title>一般科室入院护理评估单</title>
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<article class="cl">
	<form action="" method="post" class="form form-horizontal" name="form-admin-add">
		<div class="row cl">
			<div class="formControls col-sm-12">
				<h3>一、一般资料</h3>
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>性别：</label><input type="text" class="txt txtWidth50" value="" placeholder="性别" data-tag="性别">
				<label class="pl20">年龄：</label><input type="text" class="txt txtWidth70" value="" placeholder="年龄" data-tag="年龄">
				<label class="pl20">职业：</label><input type="text" class="txt" value="" placeholder="职业" data-tag="职业">
				<label class="pl20">民族：</label><input type="text" class="txt txtWidth70" value="" placeholder="民族" data-tag="民族">
				<label class="pl20">籍贯：</label><input type="text" class="txt" value="" placeholder="籍贯" data-tag="籍贯">
				<label class="pl20">文化程度：</label><input type="text" class="txt txtWidth70" value="" placeholder="文化程度" data-tag="文化程度">
				<label class="pl20">宗教：</label><input type="text" class="txt" value="" placeholder="宗教" data-tag="宗教">
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-10">
				<label>婚姻状况：</label>
				<div class="rbx">
					<input  type="radio" name="fyzk" id="fyzk1" data-tag="婚姻状况:已婚">
					<label for="fyzk1">已婚</label>
				</div>
				<div class="rbx">
					<input type="radio" name="fyzk" id="fyzk2" data-tag="婚姻状况:未婚">
					<label for="fyzk2">未婚</label>
				</div>
				<div class="rbx">
					<input  type="radio" name="fyzk" id="fyzk3" data-tag="婚姻状况:离异">
					<label for="fyzk3">离异</label>
				</div>
				<div class="rbx">
					<input type="radio"  name="fyzk" id="fyzk4" data-tag="婚姻状况:其他">
					<label for="fyzk4">其他</label>
				</div>
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>家庭地址：</label>
				<input type="text" class="txt txtWidth800" value="" placeholder="" name="家庭地址" data-tag="家庭地址"/>
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-3">
				<label>入院时间：</label><input type="text" class="txt txtw" value="" placeholder="" name="入院时间" >
			</div>
			<div class="formControls col-sm-4">
				<label>通知医师时间：</label><input type="text" class="txt" value="" placeholder="" name="通知医师时间" >
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>入院方式：</label>
				<div class="cbx">
					<input type="checkbox" name="入院方式:步行">
					<label for="入院方式:步行">步行</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="入院方式:扶助">
					<label for="入院方式:扶助">扶助</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="入院方式:轮椅">
					<label for="入院方式:轮椅">轮椅</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="入院方式:平车">
					<label for="入院方式:平车">平车</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="入院方式:背送">
					<label for="入院方式:背送">背送</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="入院方式:报送">
					<label for="入院方式:报送">报送</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="入院方式:其他">
					<label for="入院方式:其他">其他</label>
				</div>
			</div>
		</div>


		<div class="row cl">
			<div class="formControls col-sm-5">
				<label>入院陪送：</label>
				<div class="cbx">
					<input type="checkbox" name="入院陪送:家人">
					<label for="入院陪送:家人">家人</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="入院陪送:朋友">
					<label for="入院陪送:朋友">朋友</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="入院陪送:其他">
					<label for="入院陪送:其他">其他</label>
					<input type="text" class="txt txtw" value="" placeholder=""  >
				</div>
			</div>

		</div>


		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>入院诊断：</label>
				<input type="text" class="txt txtWidth800" value="" placeholder="" name="入院诊断" >
			</div>
		</div>
		
		<div class="row cl">
			<div class="formControls col-sm-12">
				<h3>二、健康评估</h3>
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>既往病史：</label>
				<div class="cbx">
					<input  type="checkbox" name="既往病史:无">
					<label for="sex">无</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="既往病史:住院">
					<label for="既往病史:住院">住院</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="既往病史:手术">
					<label for="既往病史:手术">手术</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="既往病史:所患疾病名称">
					<label for="既往病史:所患疾病名称">所患疾病名称</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="既往病史:所患疾病名称内容" >
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>过敏史：</label>
				<div class="cbx">
					<input type="checkbox" name="过敏史:无">
					<label for="过敏史:无">无</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="过敏史:有">
					<label for="过敏史:有">有</label>
				</div>
				<label class="pl-20">过敏药物：</label><input type="text" class="txt txtWidth200" value="" placeholder="" name="过敏史:过敏药物" >
				<label class="pl-20">过敏食物：</label><input type="text" class="txt txtWidth200" value="" placeholder="" name="过敏史:过敏食物" >
				<label class="pl-20">其他：</label><input type="text" class="txt txtWidth200" value="" placeholder="" name="过敏史:其他" >
			</div>
		</div>

		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>饮食习惯：</label>
				<div class="cbx">
					<input  type="checkbox" name="饮食习惯:正常">
					<label for="饮食习惯:正常">正常</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="饮食习惯:异常">
					<label for="饮食习惯:异常">异常</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="饮食习惯:异常内容" >
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;嗜好：</label>
				<div class="cbx">
					<input  type="checkbox" name="嗜好:烟">
					<label for="嗜好:烟">烟</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="嗜好:酒">
					<label for="嗜好:酒">酒</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="嗜好:其他">
					<label for="嗜好:其他">其他</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="嗜好:其他内容" >
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;睡眠：</label>
				<div class="cbx">
					<input  type="checkbox" name="睡眠:正常">
					<label for="睡眠:正常">正常</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="睡眠:入睡困难" >
					<label for="睡眠:入睡困难">入睡困难</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="睡眠:易醒" >
					<label for="睡眠:易醒">易醒</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="睡眠:药物" >
					<label for="睡眠:药物">药物</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="睡眠:药物内容" >
				<div class="cbx">
					<input type="checkbox" name="睡眠:其他" >
					<label for="睡眠:其他">其他</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="睡眠:其他内容" >
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;大便：</label>
				<div class="cbx">
					<input  type="checkbox" name="大便:正常">
					<label for="大便:正常">正常</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="大便:便秘">
					<label for="大便:便秘">便秘</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="大便:腹泻">
					<label for="大便:腹泻">腹泻</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="大便:造痿">
					<label for="大便:造痿">造痿</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="大便:便血">
					<label for="大便:便血">便血</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="大便:陶土便" >
					<label for="大便:陶土便">陶土便</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="大便:失禁" >
					<label for="大便:失禁">失禁</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="大便:其他" >
					<label for="大便:其他">其他</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="大便:其他内容" >
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;小便：</label>
				<div class="cbx">
					<input  type="checkbox" name="小便:正常">
					<label for="小便:正常">正常</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="小便:尿失禁" >
					<label for="小便:尿失禁">尿失禁</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="小便:尿潴留" >
					<label for="小便:尿潴留">尿潴留</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="小便:外引流" >
					<label for="小便:外引流">外引流</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="小便:其他" >
					<label for="小便:其他">其他</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="小便:其他内容" >
			</div>
		</div>

			<div class="row cl">
			<div class="formControls col-sm-12">
				<label>肢体活动：</label>
				<div class="cbx">
					<input type="checkbox" name="肢体活动:自如">
					<label for="肢体活动:自如">自如</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="肢体活动:障碍">
					<label for="肢体活动:障碍">障碍</label>
				</div>
				<input type="text" class="txt txtWidth100"  name="肢体活动:障碍内容"/>

				<div class="cbx">
					<input type="checkbox" name="肢体活动:瘫痪">
					<label for="压疮评估:">瘫痪</label>
				</div>
				<input type="text" class="txt txtWidth100"  name="肢体活动:瘫痪内容"/>

			</div>
		</div>


		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>带管情况：</label>
				<div class="cbx">
					<input  type="checkbox" name="带管情况:无">
					<label for="带管情况:无">无</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="带管情况:有" >
					<label for="带管情况:有">有</label>
				</div>
				<input type="text" class="txt txtWidth800" value="" placeholder="" name="带管情况:有内容" >
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-3">
				<label>生命体征：&nbsp;&nbsp;&nbsp;&nbsp;</label>
				<label>体温：</label><input type="text" class="txt txtWidth100" value="" placeholder="" name="体温" >
				<label>℃</label>
			</div>
			<div class="formControls col-sm-3">
				<label>脉搏：</label><input type="text" class="txt txtWidth100" value="" placeholder="" name="脉搏" >
				<label>次/分</label>
			</div>
			<div class="formControls col-sm-3">
				<label>呼吸：</label><input type="text" class="txt txtWidth100" value="" placeholder="" name="呼吸" >
				<label>次/分</label>
			</div>
			<div class="formControls col-sm-3">
				<label>血压：</label><input type="text" class="txt txtWidth100" value="" placeholder="" name="血压" >
				<label>mmHg</label>
			</div>
		</div>
	

		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>意识状态：</label>
				<div class="cbx">
					<input type="checkbox" name="意识状态:清醒">
					<label for="意识状态:清醒">清醒</label>
				</div>
				
				<div class="cbx">
					<input type="checkbox" name="意识状态:嗜睡">
					<label for="意识状态:嗜睡">嗜睡</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="意识状态:昏睡">
					<label for="意识状态:昏睡">昏睡</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="意识状态:浅昏迷">
					<label for="意识状态:浅昏迷">浅昏迷</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="意识状态:深昏迷">
					<label for="意识状态:深昏迷">深昏迷</label>
				</div>
				
			</div>
		</div>

		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>皮肤完整性：</label>
				<div class="cbx">
					<input  type="checkbox" name="皮肤完整性:完整">
					<label for="皮肤完整性:完整">完整</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="皮肤完整性:破损" >
					<label for="皮肤完整性:破损">破损</label>
				</div>
				<div class="cbx">
					<input  type="checkbox" name="皮肤完整性:压疮">
					<label for="皮肤完整性:压疮">压疮</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="皮肤完整性:其他" >
					<label for="皮肤完整性:其他">其他</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="皮肤完整性:其他内容" >
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>自理能力：</label>
				<div class="cbx">
					<input  type="checkbox" name="自理能力:无需依赖">
					<label for="自理能力:无需依赖">无需依赖</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="自理能力:轻度依赖" >
					<label for="自理能力:轻度依赖">轻度依赖</label>
				</div>
				<div class="cbx">
					<input  type="checkbox" name="自理能力:中度依赖">
					<label for="自理能力:中度依赖">中度依赖</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="自理能力:重度依赖" >
					<label for="自理能力:重度依赖">重度依赖</label>
				</div>
			</div>
		</div>

		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>压疮评估：</label>
				<div class="cbx">
					<input type="checkbox" name="压疮评估:无危险">
					<label for="压疮评估:无危险">无危险</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="压疮评估:低度危险">
					<label for="压疮评估:低度危险">低度危险</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="压疮评估:中度危险">
					<label for="压疮评估:中度危险">中度危险</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="压疮评估:高度危险">
					<label for="压疮评估:高度危险">高度危险</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="压疮评估:极度危险">
					<label for="压疮评估:极度危险">极度危险</label>
				</div>
			</div>
		</div>


		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>跌倒/坠床评估：</label>
				<div class="cbx">
					<input type="checkbox" name="跌倒/坠床评估:低度危险">
					<label for="跌倒/坠床评估:低度危险">低度危险</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="跌倒/坠床评估:中度危险">
					<label for="跌倒/坠床评估:中度危险">中度危险</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="跌倒/坠床评估:高度危险">
					<label for="跌倒/坠床评估:高度危险">高度危险</label>
				</div>
				
			</div>
		</div>


		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>疼痛评估：</label>
				<div class="cbx">
					<input type="checkbox" name="疼痛评估:无痛">
					<label for="疼痛评估:无痛">无痛</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="疼痛评估:轻度疼痛">
					<label for="疼痛评估:轻度疼痛">轻度疼痛</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="疼痛评估:中度疼痛">
					<label for="疼痛评估:中度疼痛">中度疼痛</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="疼痛评估:重度疼痛">
					<label for="压疮评估:重度疼痛">重度疼痛</label>
				</div>
				
			</div>
		</div>

		
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>感觉：视力：右眼：</label>
				<div class="cbx">
					<input type="checkbox" name="右眼:正常" >
					<label for="右眼:正常">正常</label>
				</div>
				<div class="cbx">
					<input  type="checkbox" name="右眼:异常">
					<label for="右眼:异常">异常</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="右眼:异常内容" >
				<div class="cbx">
					<input type="checkbox" name="右眼:其他" >
					<label for="右眼:其他">其他</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="右眼:其他内容" >
			</div>
		</div>

		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
					&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;左眼：</label>
				<div class="cbx">
					<input type="checkbox" name="左眼:正常" >
					<label for="左眼:正常">正常</label>
				</div>
				<div class="cbx">
					<input  type="checkbox" name="左眼:异常">
					<label for="左眼:异常">异常</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="左眼:异常内容" >
				<div class="cbx">
					<input type="checkbox" name="左眼:其他" >
					<label for="左眼:其他">其他</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="左眼:其他内容" >
			</div>
		</div>
		
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;听力：右耳：</label>
				<div class="cbx">
					<input type="checkbox" name="右耳:正常" >
					<label for="右耳:正常">正常</label>
				</div>
				<div class="cbx">
					<input  type="checkbox" name="右耳:异常">
					<label for="右耳:异常">异常</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="右耳:异常内容" >
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
					&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;左耳：</label>
				<div class="cbx">
					<input type="checkbox" name="左耳:正常" >
					<label for="左耳:正常">正常</label>
				</div>
				<div class="cbx">
					<input  type="checkbox" name="左耳:异常">
					<label for="左耳:异常">异常</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="左耳:异常内容" >
			</div>
		</div>

		<div class="row cl">
			<div class="formControls col-sm-12">
				<label>情绪：</label>
				<div class="cbx">
					<input  type="checkbox" name="情绪:正常">
					<label for="情绪:正常">正常</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="情绪:悲伤" >
					<label for="情绪:悲伤">悲伤</label>
				</div>
				<div class="cbx">
					<input  type="checkbox" name="情绪:焦虑">
					<label for="情绪:焦虑">焦虑</label>
				</div>
				<div class="cbx">
					<input  type="checkbox" name="情绪:孤独">
					<label for="情绪:孤独">孤独</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="情绪:恐惧" >
					<label for="情绪:恐惧">恐惧</label>
				</div>
				<div class="cbx">
					<input  type="checkbox" name="情绪:兴奋">
					<label for="情绪:兴奋">兴奋</label>
				</div>
				<div class="cbx">
					<input type="checkbox" name="情绪:其他" >
					<label for="情绪:其他">其他</label>
				</div>
				<input type="text" class="txt txtWidth300" value="" placeholder="" name="情绪:其他内容" >
			</div>
		</div>
		
		<div class="row cl">
			<div class="formControls col-sm-12">
				<h3>三、专科评估</h3>
			</div>
		</div>
		<div class="row cl">
			<div class="formControls col-sm-11">
				<textarea cols="" rows="" class="textarea"  placeholder="说点什么...1000个字符以内" name="专科评估"> 
				</textarea> <!-- onKeyUp="textarealength(this,100)"-->
				<p class="textarea-numberbar"><em class="textarea-length">0</em>/1000</p>
			</div>
		</div>
		
		<div class="row cl">
			<div class="formControls col-sm-3">
				<label>评估护士：</label><input type="text" class="txt txtw" value="" placeholder="" name="评估护士" >
			</div>
			<div class="formControls col-sm-4">
				<label>评估时间：</label><input type="text" class="txt" value="" placeholder="" name="评估时间" >
			</div>
		</div>
		<br /><br /><br /><br />
	</form>
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